Broken Play Laparoscopy – What to do when there’s no findings?

Any surgeon who has done enough laparoscopy has been there. In the office it seemed like the patient
had all the classic signs of endometriosis. She had a family history of endometriosis, the pain was worse
during intercourse, worse during her period, there might have a even been a little hemorrhagic cyst that
looked “oh-so-close” to an endometrioma on ultrasound. But you got the scope in and her abdomen is
cleaner than a self-reported surgical complication list. Other than just waking up the patient and
explaining the pain must not be from gynecologic causes, what do you do? In football we have a
scenario very much like this – we call it a “Broken Play.” Basically the quarterback gets the ball and
whatever was supposed to happen that play, be it a handoff or pass suddenly cannot happen. It could
be because of unexpected coverage, or it may be the running back tripped or the receiver ran the wrong
route. Whatever the reason, the quarterback ends up with the ball in a collapsing pocket, wondering if
there’s any way he can make something good happen out of the horrible turn of events that have
unfolded for him. I’ve heard many ideas about what to do in this scenario, so I’ll cover a few of them in
detail.

“Almost” Incidental Appendectomy

We all know that appendix is going to look a little injected. Does that mean it deserves to go? Do you
even have privileges to remove it at this hospital (or surgery center?) The nurse thinks that there’s a
general surgeon a few operating rooms over, or in the cafeteria, or living just “5 minutes away.”
Generally, suspicion of acute appendicitis is considered an emergency that does not require advanced
consent. While I agree the temptation may be strong, I recommend not to perform the incidental
appendectomy unless you really feel there are compelling signs of inflammation. Proactively, however, I
do recommend discussing the appendectomy with all patients who have primarily right sided pelvic pain
before surgery, although I can’t say I always remember to do it. It really should be something to think
about consenting the patient for whenever you are going in for right sided pelvic pain without a clear
cause. I recommend going so far as to asking the patient ahead of time “if I don’t find anything, would
you want your appendix removed? ”

“Desperation” Ovarian Cystectomy

As gynecologic surgeons we are sometimes put in a real dilemma as to whether or not to remove a
normal appearing ovary that really seems like the cause of the pain. If you’re like me, it really takes a
high threshold to remove an otherwise normal appearing ovary, just because it is assumed to be the
unproven cause of the patient’s pain. Cystectomy, on the other hand, backed by clinical suspicion, can
appear as a seemingly free move in the uncomfortable case of a laparoscopy devoid of findings. We can
always find a small follicle that could be the cause of the pain, right? With less than a third of ovarian
tissue being required to maintain hormonal support, one could also ask the question of why you would
not try to fix the patient’s pain with a generous ovarian cystectomy? After all, you are already in her
abdomen! The answer, of course, lies with our hippocratic responsibility, and the possible damage to
the women’s future fertility, as well as the unlikely, but possible loss of the ovary.

Intra-Abdominal Local Anesthetics

Although supported by a paucity of data, the intra-abdominal use of marcaine or other local numbing
agents, whether sprayed at the target area of pain, or simply injected into the abdominal cavity, can
considered in the absence of other treatable causes of pelvic pain. The logic, at least, makes sense. The
possibility of interrupting a theoretical abhorrent neurologic pathway that was eternally fixed on
reporting horrific non-existent pain may seem tempting and without risk, but some pitfalls must be
understood. cJust as we are able to perform dialysis using the physiology of the abdomen, fluid in the
abdominal cavity can quickly become intravascular. High doses of these medications can cause Local
Anesthetic System Toxicity, (LAST Syndrome) so you will need to know your patient’s weights off hand
for safe, effective usage. With the exception of this caveat, there is little harm in using small doses of
local anesthetic in the abdomen.

Gentle Hydrodistention

The jury is still out as to whether an old fashioned gentle hydrodistention of the bladder is a good way to
diagnose and treat interstitial cystitis. There is no doubt, however, that quite a few patients will give a
very impressive display of bladder petechial lesions after being stretched to about the 300cc mark.
Whether all those patients have pain from IC is another story. With the high correlation between
interstitial cystitis and endometriosis, it certainly makes sense to continue your quest to find the cause
of your patient’s pain in the bladder after coming up empty handed in the pelvis. This almost risk-free
exploration makes an attractive go-to for any pelvis who’s pain could be explained by a condition in the
bladder.

Close up and Declare Victory

Is there anything wrong with just dessufflating the abdomen and hoping that the sheer act of having
insufflated it will help with your patient’s pain? While probably just wishful thinking on our parts as
surgeons, there is some data behind the placebo effect of laparoscopy even in the absence of
discovered pathology.

I have heard many of my colleagues tell family members in the waiting room
that if you just tell her “they fixed everything,” when they wake up – they will feel a ton better. I’m
honestly not sure whether this is the power of positive thinking or straight-forward dishonesty.
Nonetheless, a placebo effect can never be completely discounted, and there probably isn’t much use in
telling a patient that she definitely will not feel better after her surgery.

In conclusion, I hope you, me, and all our colleagues never find ourselves operating with no explanation
for a patient’s pelvic pain, or in a “Broken Play Laparoscopy” as I have described it. I would encourage
those of you that do find yourself in this situation to consider your next moves based on your training,
intuition, and what little evidence you find available. I can only hope that I may have helped with a little
insight into this difficult scenario.

“I delivered both my beautiful babies with Dr. Marchand and I wouldn’t have it any other way! Every doctor visit up until I was in labor was great, he took all the time to answer all my questions. I didn’t feel rushed in and rushed out of the office. The office was always very clean! The staff were always very friendly. When I was in labor he made sure my birth plan was the most important thing! He always had my best interest in hand! My first delivery I was induced and it took 3 long days and Marchand kept checking on me all hours of the night!! If I did it all over again I’d definitely use Marchand as my OB again!”

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Alex S.

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Ashley DuBray, Senior Director of the Surgical Review Corporation

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Megan E. of Gilbert, AZ

“Growing up I have had my fair share of woman health issue from Endometriosis, PCOS, Severe Pelvic Pain, Loss of Pregnancy and Infertility and more pelvic surgeries than I can count. I have seen many different doctors till about 6-7 years ago when I needed emergency surgery and met Dr. Marchand and now I refuse to go to any one else. With the many issues I have had both Dr. Marchand as well as his whole office staff have been so helpful I couldn’t be more grateful. It’s very hard to find an honest, trustworthy doctor these days but rest assured you can’t go wrong with Dr. Greg Marchand. They are open late and almost always can fit you into the schedule for emergencies and you can always reach him no matter what time it is if you have questions. Dr. Marchand is an amazing surgeon and loves what he does. He has delivered many friends and family’s children and hope that one day he will be able to deliver mine as well.”